Page 24 - Ipsos

IPSOS STAT FZ LLC

Attached to and forming part of the Policy No: - TBA

(Policy Period: - September 28th, 2016 To December 31st, 2017)

BENEFIT SCHEDULE – CLASSIC PLAN – CATEGORY A – Non Abu Dhabi

18 Dental Treatment: Costs charges and fees Full Refund, however, any surgery must be performed
for dental treatment will be restricted to
those incurred in an emergency for the
immediate relief of pain as a result of an within 7 days from the date of accident.
accident only.

Alternative Treatment restricted to Upto limit of Dhs. 1,600/- Per Person Per Annum,
19 Chiropractory and Osteopathy however, purely on reimbursement basis

BASIS OF CLAIM SETTLEMENT: -

IN-PATIENT BENEFIT

i) Network - Within UAE i) 100% covered under Free Access Plan.

ii) Non-Network (within UAE) ii) 100% of the equivalent of the UAE General Network
tariff rates unless it is an Emergency as defined in the
20 (i) Policy and the reimbursement will be based on 100%
of the General Network rates.

iii) Treatment at Government Hospitals iii) Reimbursed at 100% of UAE General Network rates

iv) Outside UAE within Geographical iv) 100% reimbursed as cost incurred subject to the
Scope of Territory applicable deductible / co-charges as per the terms and
conditions in the Policy not exceeding 100% of UAE
General Network rates.
OUT-PATIENT BENEFIT

i)Network - Within UAE i) 100% covered under Free Access Plan.

ii)Non-Network (within UAE) ii) 100% of the equivalent of the UAE General Network
tariff rates unless it is an Emergency as defined in the
Policy and the reimbursement will be based on 100% of
20 (ii) the General Network rates.

iii)Treatment at Government Hospitals iii)Reimbursed at 100% of UAE General Network rates

iv)Outside UAE within Geographical iv) 100% reimbursed as cost incurred subject to the
Scope of Territory applicable deductible / co-charges as per the terms and
conditions in the Policy not exceeding 100% of UAE
General Network rates.